Practice Quiz

NCLEX-RN

Category - Physiological

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Maria Nunez, a 28-year-old female, is admitted due to an infected wound that resulted in necrosis and the production of abscesses along the lymph nodes of the affected leg. Surgery was done to excise the infected tissue and a skin graft was placed to cover the affected part. After surgery, which of the following instructions should the nurse give to the client to facilitate rapid healing?
  1. Avoid unnecessary movement of the affected site.
  2. Elevate the affected extremity for the first week.
  3. Keep the dressing in place for 72 hours after surgery.
  4. Initiate vigorous range of motion exercises to increase blood circulation
Explanation
Answer: A - To facilitate rapid healing, avoid unnecessary movement of the affected site or skin graft, as excessive movement will stretch and disturb the skin graft causing bleeding and swelling. Instruct the client to elevate the site of the skin graft for the first 24-48 hours. The dressing is kept in place for seven days to avoid infection. Range of motion exercises should be introduced gradually.
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